*Purpose: Highly sensitized patients (panel reactive antibody [PRA] ≥50%) are known to be at risk for poor outcome after heart transplantation (HTx). In our program, these patients undergo desensitization therapy with combinations of intravenous immune globulin (IVIG), rituximab, bortezomib, and plasmapheresis. As long as there is a negative prospective CDC crossmatch, we proceed with HTx. For these patients, we have used a protocol of postoperative rabbit anti-thymocyte globulin (rATG) 1.5 mg/kg daily x 5 followed by IVIG 1 gm/kg daily x 2 in the immediate post-transplant period. They are given maintenance therapy with tacrolimus, mycophenolate, and prednisone. We reviewed our large, single center database to assess whether highly sensitized patients under our rATG-based regimen have acceptable post-transplant outcomes.

*Methods: Between 2010 and 2017, we assessed 149 HTx patients who were sensitized (PRA ≥10%). This group was subdivided into those with PRA ≥50% and those with PRA 10-49%. A group of patients without sensitization (PRA 0%) was used as a control in a contemporaneous time period. Patients with PRA ≥10% were treated with desensitization therapy as noted above. Endpoints included 3-year survival, 3-year freedom from CAV (stenosis ≥30%), 3-year freedom from non-fatal major adverse cardiac events (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke), and 1-year freedom from development of de novo donor specific antibodies (DSA), any treated rejection (ATR), acute cellular rejection (ACR), and antibody-mediated rejection (AMR).

*Results: Highly sensitized patients with PRA ≥50% (mean 81%, n=85) compared to the PRA 10-49% (mean 27%, n=64) and PRA 0% (n=125) groups had similar 3-year survival, freedom from CAV, freedom from NF-MACE, and 1-year freedom from ACR. However, the highly sensitized group had a lower freedom from the development of DSA and episodes of ATR and AMR in the first year following HTx. (See table.)

*Conclusions: Highly sensitized patients can undergo HTx with acceptable outcomes under rATG/IVIG post-transplant regimen. Not unexpectedly, there is more DSA and AMR post-transplant in these highly sensitized patients, but these do not affect intermediate-term outcome.

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